Retrospective Chart Research Articles

The Bipolar Hip: How Acetabular and Femoral Pathomorphology Affects Hip Motion in Femoral Acetabular Impingement Syndrome

To investigate the individual and combined contributions of acetabular and femoral morphology to hip range of motion (ROM) in patients with femoroacetabular impingement syndrome (FAIS) by use of computed tomography measurements and hip ROM evaluated on physical examination. A retrospective chart and radiographic analysis of patients presenting with hip pain suggestive of FAIS was performed. The femoral neck-shaft angle, femoral version, magnitude and clock-face location of the alpha angle, midcoronal center-edge angle (CEA), midsagittal CEA, acetabular version, and McKibbin index were measured on computed tomography scans. Univariate and multivariate linear regression analyses determined which measurements correlated with hip ROM, including hip flexion as well as hip internal and external rotation with the hip in 90° of flexion. Two hundred hips that met the inclusion and exclusion criteria during the eligibility period were included in the analysis. The mean age was 31.9 ±10.0 years, there were 145 female patients (72%), and the mean body mass index was 25.2 ± 5.0. Multivariate linear regression analysis showed that the midsagittal CEA was the only measurement correlating with flexion (q= .031) whereas the femoral neck-shaft angle and McKibbin index were the only significant variables that correlated with external rotation (q= .031 and q < .001, respectively). Finally, the McKibbin index and maximum alpha angle were the only variables that correlated with internal rotation (q < .001 and q= .034, respectively). Multivariate analysis showed that combined acetabular and femoral version significantly correlated with internal and external rotation whereas femoral version in isolation did not. Increased cam morphology remained a significant contributor to reduced internal rotation but did not affect hip flexion. These data suggest that hip ROM is affected by both femoral pathomorphology and acetabular pathomorphology and that careful evaluation of both should be conducted prior to corrective osteoplasty or osteotomy. Level IV, retrospective case series.

Characteristics of Trocar Site Hernia after Laparoscopic Cholecystectomy

Trocar site hernia (TSH) is an incisional hernia occurring at the trocar insertion sites after different types of laparoscopic surgeries. The aim of this study is to present characteristics of patient and surgery series with trocar site hernia after laparoscopic cholecystectomy. A 2930 consecutive patients underwent laparoscopic cholecystectomy in two major university- affiliated hospitals from April 2014 to March 2018 and the patient followed up for variable periods of time. Retrospective medical chart review to study trocar site hernia including patient, operation, instruments, and pathologic characteristics described. Six patients had trocar site hernia (incidence 0.20%), the hernias occurred mostly at the umbilical port site after using 10 mm trocar. Risk factors included mainly obesity, female gender and use of 10 mm trocars at midline sites. TSH is more described. It occurs mostly at the umbilical port site. Major risk factors include obesity, diabetes mellitus, lengthy procedure, extension of entry site, and wound infection. Closure of fascial defect is supposed to reduce the incidence despite weak evidence.

Abstract P6-08-38: Evaluation of adherence to NCCN guidelines regarding genetic evaluation of patients with breast or ovarian cancer diagnoses in a community hospital setting

Abstract Background: The National Comprehensive Cancer Network (NCCN) guidelines provide recommendations for which patients diagnosed with breast or ovarian cancer should have a referral for genetic evaluation. However, in a community setting without access to an on-site genetics provider, providing genetic counseling or testing could be more difficult. Objective: The study objective was to evaluate which patients within a community cancer program appropriate for genetic referral actually received counseling or testing, and identify any changes in practice after initiation of an on-site genetics program. Methods: Utilizing an institutional tumor registry database, patients from a community oncology program were identified who met a subset of NCCN guidelines for genetic referral from June 2015 through June 2017. Patients diagnosed with ovarian cancer, breast cancer diagnosed at or before age 45, male breast cancer, and triple negative breast cancer diagnosed at or before age 60 were included. A retrospective electronic chart review was performed to evaluate for genetic referral and uptake of genetic testing. Patients who received genetic testing prior to a cancer diagnosis were excluded from evaluation. Results: A total of 103 patients were included (35 ovarian cancer; 62 breast cancer ≤ age 45; 1 male breast cancer; 17 triple negative ≤ age 60). A total of 76 patients had genetic testing (74%). An additional 5 patients were offered genetic testing or referred for a genetic consult but declined, bringing the total referred or tested to 78.6%. Patients with breast cancer indications had the highest rate of genetic testing (88%). Patients with ovarian cancer were tested at a lower rate (45%). A secondary analysis was performed comparing the length of time between diagnosis and testing before and after the initiation of an on-site genetics program in late July 2016. For patients with breast cancer diagnosed at or under age 45, prior to on-site genetics availability, the average time to test was 62 days (6-1021 days, with 2 patients tested prior to their diagnosis). After the genetics program started, the average time to test was 23 days (6-141 days). For patients with triple negative breast cancer diagnosed at or under age 60, the time to test went from 106 days (8-767 days) to 29 days (6-116 days). For patients with ovarian cancer, time to test went from 296 days (80-810 days) to 116 days (13-230 days). Conclusions: Within our community cancer program, there was a reasonable rate of genetic referral or genetic testing for patients with breast cancer indications per a subset of the NCCN guidelines. The rates of referral or testing were worse for ovarian cancer patients, reflecting the more acute presentation of many of these patients. There exists opportunity for improvement for testing of ovarian cancer patients including availability of inpatient consultation or testing. In addition, this study did not evaluate those patients meeting NCCN guidelines for testing based on family history, which may reflect different referral or testing patterns. For all indications, the average time from diagnosis to testing decreased with the initiation of an on-site genetics program. Citation Format: Kristine M. King, Shannon Huffaker, Dione Froman. Evaluation of adherence to NCCN guidelines regarding genetic evaluation of patients with breast or ovarian cancer diagnoses in a community hospital setting [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-08-38.

Determining when endoscopic ultrasound (EUS) changes management for patients with pancreatic cystic neoplasms.

641 Background: Pancreatic cystic neoplasms (PCNs) are being incidentally detected at an increased rate due to the widespread use of CT and MRI. CT and MRI cannot always differentiate between malignant and benign PCNs. EUS is an emerging tool that provides higher quality descriptions of pancreatic cysts and can be used to differentiate between benign and malignant features. Considering that EUS is a resource dependent tool, we hope to identify the PCN cases in which EUS changes management. Methods: We conducted a retrospective case-control chart review evaluating patients, who were diagnosed with pancreatic cysts and underwent EUS for analysis between January 1, 2010 and December 31, 2017. We determined whether EUS correctly identified high-risk features (HRFs) relative to CT/MRI and whether EUS upstaged or downstaged the CT/MRI diagnosis to change overall patient management. Results: EUS was found to have a high specificity (&gt; 95%) for all high-risk features identified in the AGA and FG guidelines and a low sensitivity ( &lt; 70%) for all high risk features except cyst size &gt; 3cm (82.35%) and mural nodule &lt; 5mm (100%). EUS was found to change management in 29.4% of cases (18.2% upstaged, 11.2% downstaged). EUS screening led to a total of three adenocarcinoma diagnoses, in which two were reported to be invasive. Conclusions: The high specificity of EUS supports its use in the differentiation of high risk PCNs identified on cross-sectional imaging. Its low sensitivity indicates that the reliance on operator experience may be a substantial limitation resulting in inconclusive diagnoses. In conclusion, considering that EUS is successful in changing patient management of PCNs, it should be readily referred when any HRF is identified on cross-sectional imaging.

Outcomes of out-of-hospital extracorporeal membrane oxygenation transfers: significance of initiation site and personnel.

Extracorporeal membrane oxygenation is an accepted therapy option for refractory cardiac or respiratory failure. The outcomes of cases initiated at non-extracorporeal membrane oxygenation centers and subsequently transported for management to an extracorporeal membrane oxygenation center require further investigation. Retrospective institutional review board-approved database research and chart reviews were performed on referrals for extracorporeal membrane oxygenation initially admitted to an outside non-extracorporeal membrane oxygenation center hospital (OSH) then transferred to our extracorporeal membrane oxygenation center (Thomas Jefferson University Hospital (TJUH)). Unstable patients were placed on extracorporeal membrane oxygenation at OSH (Group A) before transport, while others were initiated at our certified extracorporeal membrane oxygenation center (Group B) upon arrival. Group A was further subdivided into patients cannulated by OSH personnel (Group AOSH) or TJUH transport team (Group ATJUH). Outcomes and complications were compared between the different initiation sites and personnel. A total of 108 patients were transferred from August 2010 to June 2018. The technical complication rate for all Group A patients was 33/49 (67%), while that of Group B was 24/59 (41%); p = 0.006. Within Group A, Group AOSH had a greater technical complication rate with 29/33 (88%) than Group ATJUH with 4/16 (25%); p < 0.001. extracorporeal membrane oxygenation survival rate was 34/49 (69%) in Group A and 43/59 (73%) in Group B; p = 0.690. The extracorporeal membrane oxygenation survival rate for Group AOSH and Group ATJUH was 21/33 (64%) and 13/16 (81%), respectively; p = 0.210. Promising extracorporeal membrane oxygenation survival rates were observed in transferred patients. The complication rates related to cannulation technique were significantly higher when patients were initiated at non-extracorporeal membrane oxygenation centers, especially when placed by personnel from non-extracorporeal membrane oxygenation centers.

Identifying Aspiration Among Infants in Neonatal Intensive Care Units Through Occupational Therapy Feeding Evaluations.

When a neonate's sucking, swallowing, and breathing are disorganized, oropharyngeal aspiration often occurs and results in illness, developmental problems, and even death. Occupational therapists who work in the neonatal intensive care unit (NICU) need to identify neonates who are at risk for aspirating so they can provide appropriate treatment. To ascertain whether client factors and performance skills of infants ages 0-6 mo during occupational therapy feeding evaluations are related to results of videofluoroscopic swallowing studies (VFSSs). Retrospective chart reviews. 187-bed NICU in a nonprofit teaching hospital. A purposive sample of 334 infants ages 0-6 mo, ≥33 wk gestational age at birth, admitted to a Level II, III, or IV NICU as defined by the American Academy of Pediatrics. Neonates were administered a feeding evaluation by an occupational therapist and a VFSS by a speech-language pathologist, which yielded information about client factors and performance skills. Signs and symptoms of aspiration on the evaluations were significantly associated with VFSS results. Of 310 patients, 79 had silent aspiration. Of 55 infants who demonstrated no aspiration symptoms during the feeding evaluation, 45% demonstrated aspiration symptoms on the VFSS, and 55% aspirated on the VFSS but demonstrated no symptoms of aspiration. Aspiration among infants occurs inconsistently and depends on client factors, contexts, and environments. Occupational therapists are encouraged to assess an infant's feeding over several sessions to obtain a more accurate picture of the infant's feeding status. This study provides information that helps occupational therapists identify infants at risk for aspiration and make optimal recommendations regarding safe feeding practices and appropriate referrals for a VFSS. Making appropriate referrals for VFSS is also important in preventing unnecessary exposure to radiation for preterm infants.

An alternative fixation method for femoral varus derotational osteotomy in spastic cerebral palsy: the Rush rod.

The objective of this study is to present the clinical and radiographic data collected from patients who were treated with a varus derotational osteotomy using Rush rod fixation and compare this to published norms of outcomes using blade plate fixation. A retrospective chart and radiograph review was conducted after identifying 44 patients with 61 hips who underwent varus derotational osteotomy with Rush rod fixation at our institution between 2006 and 2016. We identified 44 patients with 61 hips who underwent the procedure. Information from follow-up clinic visits was gathered and any complications were noted. The patients' radiographs were analyzed to measure neck-shaft angle, center-edge angle, and acetabular index. At the time of surgery, 44 patients (61 hips) also had soft tissue releases performed, 44 (61 hips) had an open reduction of the hip, and 39 (55 hips) had Dega acetabular osteotomies performed as well. The average pre-operative neck-shaft angle was measured at 163.0° (range 128-180) with average post-operative neck-shaft angles measuring 111.3° (range 85-167). The acetabular index improved from an average of 33.3° (range 16-60) to 16.4 (range 4-35). Post-operative Center-Edge Angle measured 29.7° (range 5-45). There were no infections or cases of avascular necrosis of the femoral head. We present an alternative fixation method for performing varus derotational osteotomy of the proximal femur in children with cerebral palsy using the Rush rod. In our retrospective analysis of 61 hips undergoing this procedure, we present comparable radiographic outcomes with decreased complication rates. Level of evidence: Retrospective comparative study to previously published results, Level III.

Technique Survival and Determinants of Technique Failure in In-Center Nocturnal Hemodialysis: A Retrospective Observational Study.

Background:Long-duration (7-8 hours) hemodialysis provides benefits compared with conventional thrice-weekly, 4-hour sessions. Nurse-administered, in-center nocturnal hemodialysis (INHD) may expand the population to whom an intensive dialysis schedule can be offered.Objective:The primary objective of this study was to determine predictors of INHD technique failure, disruptions, and technique survival.Design:This study used retrospective chart and database review methodology.Setting:This study was conducted at a single Canadian INHD program operating in Victoria, British Columbia, within a tertiary care hospital. Our program serves a catchment population of approximately 450 000 people.Patients/Sample/Participants:Forty-three consecutive incident INHD patients took part in the INHD program of whom 42 provided informed consent to participate in this study.Methods:We conducted a retrospective observational study including incident INHD patients from 2015 to 2017. The primary outcome was technique failure ≤6 months (TF ≤6). Secondary outcomes included technique survival and reasons for/predictors of INHD discontinuation or temporary disruption. Predictors of each outcome included demographics, comorbidities, and Clinical Frailty Scale (CFS) scoring.Results:Among 42 patients, mean (SD) age, dialysis vintage, CFS score, and follow-up were 63 (16) years, 46 (55) months, 4 (1), and 11 (9) months, respectively. 52% were aged ≥65 years. TF ≤6 occurred in 12 (29%) patients. One-year technique survival censored for transplants and home dialysis transitions was 60%. Discontinuation related to insomnia (32%), medical status change (27%), and vascular access (23%). In unadjusted Cox survival analysis, 1-point increases in CFS score associated with a higher risk of technique failure (hazard ratio: 2.04, 95% confidence interval [CI]: 1.26-3.31). In an adjusted analysis, higher frailty severity also associated with temporary INHD disruptions (incidence rate ratio: 2.64, 95% CI: 1.55-4.50, comparing CFS of ≥4 to 1-3).Limitations:The retrospective, observational design of this study resulted in limited ability to control for confounding factors. In addition, the relatively small number of events observed owing to a small sample size diminished statistical power to inform study conclusions. Use of a single physician to determine the clinical frailty score is another limitation. Finally, the use of a single center for this study limits generalizability to other programs and clinic settings.Conclusions:INHD is a sustainable modality, even among older patients. Higher frailty associates with INHD technique failure and greater missed treatments. Inclusion of a CFS threshold of ≤4 into INHD inclusion criteria may help to identify individuals most likely to realize the long-term benefits of INHD.Trial Registration:Due to the retrospective and observational design of this study, trial registration was not necessary.

Demography and Treatment of Complex Regional Pain Syndrome Among Children

Introduction: Complex Regional Pain syndrome (CRPS) is a rare chronic pain syndrome characterized by amplified pain and autonomic dysfunction. A systematic multidisciplinary treatment program for affected children exists at our department. This study aims to estimate the incidence of CRPS and describe the demography, symptoms and psychosocial characteristics of the patients and evaluate the treatment results. Method: A retrospective medical chart review of all patients under the age of 16 years treated for CRPS between 2004 and 2014 at Hans Christian Andersen Children Hospital. Results: A total of 29 children fulfilled the diagnostic criteria for CRPS. The mean incidence was 2,4/100.000 children per year. Most patients were girls (90%) with a median age of 11 years. A lower extremity was most often involved (86%). Time to diagnosis had a mean of 174 days. All patients reported complete disappearance or significant reduction of pain at discharge without any medication. Walking was normalized in 75% and almost 1/3 could run normally. School attendance and social life was restored. Conclusion: The typical child with CRPS is a girl of normal stature, around 11 years old, who is affected by intolerable pain in a lower extremity and has severe limitation in walking. The condition is rare with a mean incidence of 2,4/100.000 children. Attention is important in order to reduce the diagnostic delay. Our treatment program was successful as the children were in reduced pain, gaining normal physical function and out of social isolation at completion of the program.

The learning curve for robotic-assisted pyeloplasty in children: Our initial experience from a single center.

Background:Robotic-assisted pyeloplasty surgery has become the preferred approach of ureteropelvic junction obstruction (UPJO) in pediatrics. However, to our knowledge, there is limited data on the learning curve for robotic-assisted pyeloplasty in children and no similar study from Saudi Arabia.Aims:The objective of the study was to evaluate the progression of the surgical team performing robotic-assisted laparoscopic pyeloplasty (RALP) and to assess the feasibility of the RALP in children, since it is having been recently started in the Kingdom.Settings and Design:Retrospective charts and surgical videos review at the tertiary care centre.Subjects and Methods:After approval from the internal review board (IRB), we reviewed the surgical video recording of the RALP procedure of 15 patients presented with UPJO from January 2016 to October 2017. Statistical analysis was done for the variables includes dissection time, pyelotomy, anastomosis on both sides, and total surgery time and calculated in minutes. Renal ultrasound reviewed to assess any change in grade.Results:Fifteen patients with UPJO underwent RALP. Of 15 cases, nine were primary and six cases as secondary UPJO. The median age was 8 (3–15) years. Out of 15 cases, 13 and 2 patients diagnosed as Society for Fetal Urology grades of 4 and 3, respectively. Total operative time was prolonged in secondary group as compared to primary pyeloplasty group (mean [standard deviation (SD)]: 166.3 [35.1], range: 125–223, P = 0.0028 versus mean (SD): 149.17 (30.4), range: (114–207), P = 0.0008). The success rate was 100% in primary and 84% in secondary cases. The median length of follow-up was 12.0 (7.0–18.0) and 10.0 (8.0–12.5) months in primary and secondary cases, respectively. The overall complication rate was 13% (2/15) (Clavien grade: 1–2).Conclusions:The evaluation of the learning curve of RALP for this group of patients concluded that total operative time for RALP, performed by the pediatric urology team, steadily decreased with collective surgical experience.

Incidence of Glaucoma or Ocular Hypertension After Repeated Anti-Vascular Endothelial Growth Factor Injections for Macular Degeneration.

PurposeTo estimate the risk of glaucoma or sustained ocular hypertension (OHT) related to anti-vascular endothelial growth factor (VEGF) injections for age-related macular degeneration (AMD).DesignRetrospective chart review.SubjectsPatients who received unilateral anti-VEGF injections for AMD at the Wheaton Eye Clinic (IL).MethodsChart analysis was performed on 1095 patients, without prior glaucoma or OHT, who received unilateral anti-VEGF injections for AMD from 2005 to 2012, with data collected through 2013. Data collection included demographics, lens status, date and medication type of each injection, and the date of diagnosis of glaucoma or OHT by a treating glaucoma specialist, which was the main outcome measure. Rare events logistic regression was performed to determine the risk of disease development based on sex, lens status, and injection frequency.ResultsUnilateral glaucoma or sustained OHT developed in 42 patients over the course of follow-up, with 40 events in the injected eye only, 2 in the contralateral eye only. Statistical modeling predicted elevated risk for onset of glaucomatous disease with a higher maximum frequency of injections (p < 0.0001, odds ratio [OR] 2.18 for each additional injection over the most injection-intense 6 months for a given subject) and with phakic lens status (p = 0.0009, OR 0.33 for pseudophakia).ConclusionOur results show a significant risk for glaucoma or OHT development in patients undergoing repeated treatments with intravitreal anti-VEGF injections for AMD, establishing the first reliable connection between disease development and a period of high-frequency injections. In addition, we show a significantly increased risk of disease development in phakic patients, which we believe points to a mechanical explanation for this type of secondary glaucoma.

Malaria and the climate in Karachi: An eight year review.

Background and Objective:Malaria is an arthropod-borne infectious disease transmitted by the mosquito Anopheles and claims millions of lives globally every year. Reasons for failure to eradicate this disease are multifactorial. The seasonality of the malaria is principally determined by climatic factors conducive for breeding of the vector. We aimed to study the relationship between climatic variability and the seasonality of malaria over an eight-year duration.Methods:This was a retrospective medical chart review of 8,844 confirmed cases of malaria which presented to The Indus Hospital, Karachi from January 2008 to November 2015. Cases were plotted against meteorological data for Karachi to elicit monthly variation.Results:A secular incline and seasonality in malaria cases over the duration of eight years was seen. More cases were reported in the summer, rainy season compared with the other three seasons in each year. There was significant association with specific climate variables such as temperature, moisture, and humidity.Conclusion:There is a marked seasonal variation of malaria in Karachi, influenced by various environmental factors. Identification of the ‘the concentrated period’ of malaria can be helpful for policymakers to deploy malaria control interventions.

Risk Factors Associated With Femoral Ring Allograft Breakage in ALIF.

Study design:This is a retrospective chart review.Objectives:To identify the incidence of, and variables correlated with, femoral ring allograft (FRA) fracture following anterior lumbar interbody fusion (ALIF).Methods:All patients who underwent ALIF using FRAs at an academic institution over 10 years were included. Postoperative radiographs were reviewed by both the primary and senior authors; fracture and no-fracture groups were created for comparison. Patient and surgical characteristics were extracted from electronic medical records. Frequency data comparisons were performed using contingency table analysis; comparisons of means were analyzed for continuous variables. A multivariate linear regression model was developed using screw use, graft height <12 mm, index level, and weight as variables.Results:A total of 76 FRAs in 59 patients were identified, 13 (17%) of which fractured. Age, sex, smoking status, use of buttress screws, weight, index level, and presence of spondylolisthesis were not correlated with incidence of fracture (P > .05). There was a significant correlation between the height of FRA and incidence of fracture; 2% (1/52) of grafts ≥12 mm and 50% (12/24) of grafts <12 mm fractured (P < .0001). Using ordinary least-squares regression, this result was independent of patient weight, use of screws, and index level. Of 10 patients, 9 did not require revision surgery to achieve fusion.Conclusions:Graft height was the only variable correlated with incidence of FRA fracture. Graft height <12 mm is an independent risk factor for FRA fracture in patients undergoing ALIF, and their use should be avoided in ALIF procedures.

Emicizumab prophylaxis in patients with haemophilia A with and without inhibitors.

Emicizumab is a bispecific monoclonal antibody that mimics factor VIII (FVIII) by binding to factors IXa and X to promote hemostasis in haemophilia A (HA) and HA with inhibitors (HA-I). As emicizumab differs biochemically from FVIII, there is interest in its real-world haemostatic efficacy. To describe real-world patient experience with emicizumab by retrospective chart review. We reviewed medical records of patients cared for at the Hemophilia Center of Western PA, who initiated emicizumab following its licensure, and on whom bleeding events and factor use were available. Comparisons between groups were done by Student's t test for continuous data and by chi-square or Fisher's exact test for discrete data. A total of 42 patients whose charts were reviewed included 18 (42.9%) with HA and 24 (52.1%) with HA-I. Groups were similar in age, 17 (40.5%) <18years, race, and haemophilia severity, and initiated weekly subcutaneous emicizumab 1.5mg/kg, following 4-week induction. Fourteen (33.3%) experienced at least one breakthrough bleed, of which 11 (44.0%) were joint bleeds, with an annualized bleed rate (ABR), 0.9±0.3, not different between groups, P=.251. Surgical procedures were performed in 10 (23.8%), of whom 4 (40.0%) had postoperative bleeding and one developed postoperative thrombosis in association with FEIBA despite emicizumab discontinuation 1month preoperatively. Local skin reactions occurred in three and headache in one. Overall, 85.0% of those who rated their health indicated it was improved. Despite breakthrough bleeds and postoperative thrombosis associated with emicizumab, most HA and HA-I experienced improved health.

High Resolution DNA Typing of Human Leukocyte Antigen A29 in Familial Birdshot Chorioretinopathy

ABSTRACT Purpose: To describe high-resolution DNA typing of HLA-A29 in patients with familial birdshot chorioretinopathy (BSCR). Methods: A retrospective clinical chart review was performed of all patients at the Francis I. Proctor Foundation with BSCR with a documented family history of HLA-A29 positive BSCR. High-resolution HLA-A29 typing was performed for these patients. Results: Two families with familial BSCR were identified. Family 1 consisted of a mother, daughter and maternal aunt with BSCR. All were positive for the HLA-A29*02 allele. Family 2 consisted of two sisters with BSCR who were both positive for the HLA-A29*02 allele. Conclusions: Familial BSCR is rare and we report the high-resolution DNA typing of HLA-A29 in two families with familial BSCR and their associated clinical outcomes, including the first documented case of multigenerational BSCR.

High-frequency oscillatory ventilation in a tertiary paediatric intensive care unit in an academic hospital in Johannesburg, South Africa.

High-frequency oscillatory ventilation (HFOV) remains an option for the management of critically ill children when conventional mechanical ventilation fails. However, its use is not widespread, and there is wide variability reported with respect to how it is used. To describe the frequency, indications, settings and outcomes of HFOV use among paediatric patients with a primary respiratory disorder admitted to a tertiary paediatric intensive care unit (PICU). The study was a 2-year, single-centre, retrospective chart review. Thirty-four (32.7%) patients were managed with HFOV in the PICU during the study period. Thirty-three of the 34 patients had paediatric acute respiratory distress syndrome. Indications for HFOV were inadequate oxygenation in 17 patients (50%), and refractory respiratory acidosis in 15 patients (44.1%) (2 patients did not fit into either category). Approaches to the setting of HFOV varied considerably, particularly with respect to initial pressure around the airways. HFOV was effective at improving both oxygenation, with a median (interquartile range (IQR)) decrease in oxygenation index of 6.34 (5.0 - 9.5), and ventilation with a the median decrease in PaCO2 of 67.6 (46.2 - 105.7) mmHg after 24 hours. Overall mortality was 29.4% in the HFOV group, which is consistent with other studies. HFOV remains an effective rescue ventilatory strategy, which resulted in rapid and sustained improvement in gas exchange in patients with severe hypoxaemia and/or severe respiratory acidosis, particularly in the absence of extracorporeal support. However, the variability in practice and the adverse effects described highlight the need for future high-quality randomised controlled trials to allow for development of meaningful guidelines to optimise HFOV use. This study describes the use and outcomes of high-frequency oscillatory ventilation (HFOV) in a South African paediatric intensive care unit, thus addressing a local knowledge gap and providing evidence of the continued efficacy of HFOV for severe hypoxaemia and refractory respiratory acidosis in settings without access to extracorporeal technologies.

Impact of care coordination on oral anticoagulant therapy among patients with atrial fibrillation in routine clinical practice in Japan: a prospective, observational study

BackgroundCare coordination between general practitioners (GPs) and cardiovascular specialists is expected to play a key role in establishing appropriate oral anticoagulant (OAC) treatment in atrial fibrillation (AF) patients. The aim of this study was to assess the impact of care coordination on oral anticoagulant therapy in the management of AF in Japan.MethodsThis study was a multi-center, single-arm, prospective cohort study with retrospective chart and claims data review for historical controls. The study included three study periods: a 12-month pre-campaign period; a 12-month campaign period for AF screening and care coordination; and a 3-month post-campaign period for follow-up of care coordination. During the campaign period, patients aged ≥65 years who attended participating GP clinics underwent opportunistic AF screening by GPs under the campaign. At the discretion of the GP, newly diagnosed AF patients after the screening were referred to a cardiovascular specialist for care coordination. To assess the impact of care coordination and evaluate the effects of the campaign, implementation of care coordination, antithrombotic therapies, and patient-reported outcomes were compared between patients with and without care coordination, and between patients during the pre-campaign and campaign periods.ResultsThere were 86 newly diagnosed AF patients during the pre-campaign period and 90 during the campaign period. The percentage of patients with care coordination increased from 3.5% (3/86) in the pre-campaign period to 14.4% (n = 13/90) during the campaign period. The percentage of patients who received OAC therapies, according to the definition from the Japanese AF medication guideline, increased from 55.8% (48/86) to 71.1% (64/90) during the campaign period regardless of care coordination. Younger patients were referred to cardiovascular specialists for care coordination. Implementation of OAC therapy did not differ between patients with and without care coordination. Adherence to OAC therapy was low regardless of care coordination.ConclusionsThis GP-targeted campaign was effective at raising awareness regarding the implementation of care coordination and appropriate OAC therapy at local clinical practices in Japan. Improvement of adherence to OAC therapy in elderly patients is a critical issue, and measures such as education programs targeted to patients and healthcare professionals should be undertaken.

The Fate of Unruptured Intracranial Vertebrobasilar Dissecting Aneurysm with Brain Stem Compression According to Different Treatment Modalities.

Unruptured intracranial vertebrobasilar dissecting aneurysms with brain stem compression are difficult to treat. In the present study, the clinical and radiologic outcomes of unruptured intracranial vertebrobasilar dissecting aneurysms with brain stem compression based on different treatment modalities were evaluated. This study included 28 patients with unruptured intracranial vertebrobasilar dissecting aneurysms with brain stem compression treated from January 2009 to December 2017. Treatment methods were observation (n = 6), stent-assisted coil embolization (n = 9), parent artery occlusion (n = 6), and flow diversion (n = 7). The data of baseline characteristics, change of aneurysm size, retreatment rate, stroke occurrence, and alteration of the mRS score were obtained from retrospective chart review. The initial size of dissecting aneurysms was largest in the flow diversion group (22.5 ± 7.7 mm), followed by parent artery occlusion (20.3 ± 8.4 mm), stent-assisted coil embolization (11.7 ± 2.2 mm), and observation (17.8 ± 5.5 mm; P = .01) groups. The reduction rate of aneurysm size was highest in the parent artery occlusion group (26.7 ± 32.1%), followed by flow diversion (14.1% ± 28.7%), stent-assisted coil embolization (-17.9 ± 30.3%), and observation (-31.5 ± 30.8%; P = .007) groups. Additional treatment was needed in the observation (4/6, 66.7%) and stent-assisted coil embolization (3/9, 33.3%; P = .017) groups. Improvement of the mRS score on follow-up was observed in the flow diversion (6/7, 85.7%) and parent artery occlusion (4/6, 66.7%) groups but not in the stent-assisted coil embolization and observation groups. A worsened mRS score was most common in the observation group (4/6, 66.7%), followed by stent-assisted coil embolization (3/9, 33.3%), parent artery occlusion (2/6, 33.3%), and flow diversion (0/7, 0%) groups. When treating intracranial vertebrobasilar dissecting aneurysms with brain stem compression, parent artery occlusion and flow diversion should be considered to reduce aneurysm size and improve the mRS score.

Impact of IVC Filter Guidelines, Registry, and Clinic on Filter Retrieval.

Background and hypothesis: Deep vein thrombosis (DVT) and pulmonary embolism (PE), collectively referred to as venous thromboembolism (VTE), are serious medical conditions that affect up to 900,000 Americans yearly, accounting for up to 100,000 deaths. The first line treatment for VTE is anticoagulation; however, in patients who experience a contraindication to, or failure of anticoagulation, an IVCF may be used. There are two types of IVCFs, permanent and retrievable. Retrievable filters are indicated when the contraindication to anticoagulation is transient, and they may be removed once the contraindication has passed. Retrievable filters have become associated with serious complications such as filter fracture, migration, and IVC perforation. Subsequently, they have become the subject of litigation. As such, strategies should be undertaken to reduce filter dwell time and improve filter retrieval rates. We hypothesize that implementation of IVCF guidelines, registry, and clinic will reduce dwell time while increasing retrieval rate.&#x0D; Methods: This study was a mixed retrospective and prospective chart review of patients who received an IVCF before and after implementation of IVCF guidelines, registry, and clinic. The guidelines, registry, and clinic were established in July 2017. Cases were analyzed during the years 2014-2015 (n=191) and 2017-2018 (n=103) beginning in July 2017. Data was obtained on filter retrieval rate, dwell time, filter-associated complications, and indication for placement.&#x0D; Results: There was a significant decrease in dwell time (p&lt;.001) and a significant increase in retrieval rate (p&lt;.001). There was no difference in complication rate, and there was a decrease in filter placement in patients with ‘soft’ indications, though this difference was not statistically significant (p=.109).&#x0D; Conclusion and potential impact: Implementation of dedicated efforts to increase patient follow-up and filter retrieval were effective in reducing dwell time and retrieval rate. Although there was no significant difference in complication rate, these efforts may be protective against litigation for patients who experience a filter-associated complication.

P763Home Monitoring is associated with fewer gastrointestinal bleeding events following ventricular assist device implantation

Abstract Introduction Patients (pts) treated with a continuous flow left ventricular assist device (LVAD) are at increased risk for both bleeding and thromboembolic events. Maintenance of oral anticoagulation (AC) in the therapeutic range is difficult to achieve. Hypothesis Increased frequency of international normalized ratio (INR) home monitoring (HM) decreases the incidence of gastrointestinal bleeding and thromboembolic events (stroke, pump thrombosis) compared to standard of care (SOC). Methods We analyzed the efficacy of outpatient AC monitoring in consecutive pts who underwent VAD implantation at our institution between 2008–2018. Time in therapeutic range (TTR) was defined as percent of time with INR 2.5–2.8. HM pts had biweekly INR measurements using the Coagucheck XS ROCHE, while SOC pts had INR measured every 1–3 weeks. Gastrointestinal bleeding (GIB) and thromboembolic events were assessed by retrospective blinded chart review. Logistic regression was used to model the impact of TTR on the risk of GIB and THROMB. Results There were 85 pts: 44 in HM and 40 in SC arm with similar characteristics. SOC patients were more likely to have ischemic cardiomyopathy (63% vs 30%, p=0.006) and an LVAD (60% vs 25%, p=0.002). The use of HM was associated with a 19.7% reduction in the risk of GIB (8.8% vs 28.5%, p=0.043) and a trend towards lower risk of THROMB (6.8% vs 14.9%, p=0.19). HM pts had significantly longer TTR (52±20% vs 39±22%, p=0.007). Each percentage increase in TTR was associated with a 5.2% decrease in the risk of GIB [Odds Ratio (OR) 0.95, 95% Confidence Interval (CI) 0.91–0.99, p=0.009] even after adjustment for aspirin use and monitoring duration (OR 0.95, 95% CI 0.91–0.99, p=0.020). There was a similar decrease in the risk of overall bleeding (OR 0.94, 95% CI 0.90–0.98, p=0.008). Conclusions Increased frequency of home INR monitoring achieved a higher TTR and was associated with a 20% reduction in risk of gastrointestinal bleeding.